Patient Record Release Form

Island Tower Dentistry

Patient Name *

Email *

Previous Dentist or Dental Office Name (Hermann Schulze, DDS if you are not coming from another practice) *

Record Release Agreement (Click Bubble to Agree): *

I hereby authorize the above stated dentist or dental office to provide Jonathan Van Dyke, DMD and Island Tower Dentistry with copies of my dental records with respect to any dental care and treatment I have received. I understand that the specific type of information to be disclosed includes a detailed report of examinations, treatment provided, x-rays and all other records which pertain to me. This consent is effective until such date as I can cancel this consent. I understand that the information obtained as a result of this consent may be used after the cancellation date.

Patient Signature

Clear Signature

Signature of parent, legal guardian, or POA of the patient, if patient is unable to sign for themselves

Clear Signature

Date *

Records will be sent to 606 Bald Eagle Dr. Ste 200, Marco Island, Florida 34145, or emailed to info@marcoislanddental.com. Phone: 239-394-1004

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